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Zhang XX, Yao FR, Zhu JH, Chen ZG, Shen YP, Qiao YN, Shi HC, Liang JH, Wang XM, Fang Q. Nomogram to predict haemorrhagic transformation after stroke thrombolysis: a combined brain imaging and clinical study. Clin Radiol 2021; 77:e92-e98. [PMID: 34657729 DOI: 10.1016/j.crad.2021.09.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/15/2021] [Indexed: 11/26/2022]
Abstract
AIM To construct a novel nomogram by integrating computed tomography perfusion (CTP) and clinical parameters for individualised prediction of haemorrhagic transformation (HT) in intravenous thrombolysis (IVT)-treated acute ischaemic stroke (AIS) patients. METHODS Anterior circulation AIS patients who underwent IVT at a single centre from January 2018 to June 2020 were reviewed retrospectively. The CTP parameters of two regions of interest (ROI), the entire perfusion lesion areas, and the infract core areas, were assessed. HT was documented by follow-up CT 24 ± 2 h after IVT. Multivariable logistic regression was conducted by including clinical variables and CTP parameters to identify the independent predictors of HT. A nomogram was developed based on the independent predictors. The discriminative value and calibration of the nomogram were tested by concordance indexes (C-indexes) and calibration plots. Internal validation was performed using fivefold cross-validation. RESULTS The nomogram was generated using the complete data from 341 patients. Seven variables were included in the final nomogram, including: the relative cerebral blood volume (rCBV), permeability surface (PS), and relative PS (rPS) in infract core areas, the relative time to maximum (rTmax) and rPS in entire perfusion lesion areas, the National Institutes of Health Stroke Scale (NIHSS), and atrial fibrillation (AF). The C-indexes were 0.815 and 0.817 for the nomogram and internal validation. The calibration plots showed excellent agreement. CONCLUSION This is the first study establishing a nomogram based on CTP and clinical parameters to predict HT after stroke thrombolysis.
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Affiliation(s)
- X-X Zhang
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, 224000, Jiangsu Province, China; Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - F-R Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China
| | - J-H Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - Z-G Chen
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China
| | - Y-P Shen
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, 215000, Jiangsu, China
| | - Y-N Qiao
- Department of Epidemiology and Biostatistics, School of Public Health, Medical College of Soochow University, Suzhou, 215000, Jiangsu, China
| | - H-C Shi
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, 224000, Jiangsu Province, China
| | - J-H Liang
- Department of Imaging, Medical College of Soochow University, Suzhou, 215000, Jiangsu Province, China
| | - X-M Wang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215000, Jiangsu, China.
| | - Q Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Soochow, 215000, Jiangsu, China.
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Arba F, Rinaldi C, Caimano D, Vit F, Busto G, Fainardi E. Blood-Brain Barrier Disruption and Hemorrhagic Transformation in Acute Ischemic Stroke: Systematic Review and Meta-Analysis. Front Neurol 2021; 11:594613. [PMID: 33551955 PMCID: PMC7859439 DOI: 10.3389/fneur.2020.594613] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/07/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction: Hemorrhagic transformation (HT) is a complication of reperfusion therapy for acute ischemic stroke. Blood–brain barrier (BBB) disruption is a crucial step toward HT; however, in clinical studies, there is still uncertainty about this relation. Hence, we conducted a systematic review and meta-analysis to summarize the current evidence. Methods: We performed systematic review and meta-analysis of observational studies from January 1990 to March 2020 about the relation between BBB disruption and HT in patients with acute ischemic stroke with both computed tomography (CT) and magnetic resonance (MR) assessment of BBB. The outcome of interest was HT at follow-up imaging evaluation (within 48 h from symptom onset). We pooled data from available univariate odds ratios (ORs) in random-effects models with DerSimonian–Laird weights and extracted cumulative ORs. Results: We included 30 eligible studies (14 with CT and 16 with MR), N = 2,609 patients, with 88% and 70% of patients included in CT and MR studies treated with acute stroke therapy, respectively. The majority of studies were retrospective and had high or unclear risk of bias. BBB disruption was measured with consistent methodology in CT studies, whereas in MR studies, there was more variability. All CT studies provided a BBB disruption cutoff predictive of HT. Four CT and 10 MR studies were included in the quantitative analysis. We found that BBB disruption was associated with HT with both CT (OR = 3.42; 95%CI = 1.62–7.23) and MR (OR = 9.34; 95%CI = 3.16–27.59). There was a likely publication bias particularly for MR studies. Conclusion: Our results confirm that BBB disruption is associated with HT in both CT and MR studies. Compared with MR, CT has been more uniformly applied in the literature and has resulted in more consistent results. However, more efforts are needed for harmonization of protocols and methodology for implementation of BBB disruption as a neuroradiological marker in clinical practice.
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Affiliation(s)
| | - Chiara Rinaldi
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Danilo Caimano
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Federica Vit
- NEUROFARBA Department, University of Florence, Florence, Italy
| | | | - Enrico Fainardi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Suh CH, Jung SC, Cho SJ, Kim D, Lee JB, Woo DC, Oh WY, Lee JG, Kim KW. Perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke: a systematic review and meta-analysis. Eur Radiol 2019; 29:4077-4087. [PMID: 30617485 DOI: 10.1007/s00330-018-5936-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/13/2018] [Accepted: 11/29/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To investigate the diagnostic performance of perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke. METHODS A computerized literature search of Ovid MEDLINE and EMBASE was conducted up to October 29, 2018. Search terms included acute ischemic stroke, hemorrhagic transformation, and perfusion CT. Studies assessing the diagnostic performance of perfusion CT for prediction of hemorrhagic transformation in acute ischemic stroke were included. Two reviewers independently evaluated the eligibility of the studies. A bivariate random effects model was used to calculate the pooled sensitivity and pooled specificity. Multiple subgroup analyses were performed. RESULTS Fifteen original articles with a total of 1134 patients were included. High blood-brain barrier permeability and hypoperfusion status derived from perfusion CT are associated with hemorrhagic transformation. The pooled sensitivity and specificity were 84% (95% CI, 71-91%) and 74% (95% CI, 67-81%), respectively. The area under the hierarchical summary receiver operating characteristic curve was 0.84 (95% CI, 0.81-0.87). The Higgins I2 statistic demonstrated that heterogeneity was present in the sensitivity (I2 = 80.21%) and specificity (I2 = 85.94%). CONCLUSION Although various perfusion CT parameters have been used across studies, the current evidence supports the use of perfusion CT to predict hemorrhagic transformation in acute ischemic stroke. KEY POINTS • High blood-brain barrier permeability and hypoperfusion status derived from perfusion CT were associated with hemorrhagic transformation. • Perfusion CT has moderate diagnostic performance for the prediction of hemorrhagic transformation in acute ischemic stroke. • The pooled sensitivity was 84%, and the pooled specificity was 74%.
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Affiliation(s)
- Chong Hyun Suh
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Seung Chai Jung
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.
| | - Se Jin Cho
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Donghyun Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Jung Bin Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Dong-Cheol Woo
- Bioimaging Center, Biomedical Research Center, Asan Institute for Life Sciences, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
| | - Woo Yong Oh
- Clinical Research Division, National Institute of Food and Drug Safety Evaluation, MFDS, Cheongju, Republic of Korea
| | - Jong Gu Lee
- Clinical Research Division, National Institute of Food and Drug Safety Evaluation, MFDS, Cheongju, Republic of Korea
| | - Kyung Won Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea.,Asan Image Metrics, Clinical Trial Center, Asan Institute for Life Sciences, Asan Medical Center, 86 Asanbyeongwon-Gil, Songpa-Gu, Seoul, 05505, Republic of Korea
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Kalinin MN, Khasanova DR, Ibatullin MM. A comprehensive assessment of brain perfusion data in patients with acute ischemic stroke for prediction of hemorrhagic transformation. Zh Nevrol Psikhiatr Im S S Korsakova 2019; 119:24-36. [DOI: 10.17116/jnevro201911903224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Li Y, Xia Y, Chen H, Liu N, Jackson A, Wintermark M, Zhang Y, Hu J, Wu B, Zhang W, Tu J, Su Z, Zhu G. Focal Low and Global High Permeability Predict the Possibility, Risk, and Location of Hemorrhagic Transformation following Intra-Arterial Thrombolysis Therapy in Acute Stroke. AJNR Am J Neuroradiol 2017; 38:1730-1736. [PMID: 28705822 DOI: 10.3174/ajnr.a5287] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 05/06/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE The contrast volume transfer coefficient (Ktrans), which reflects blood-brain barrier permeability, is influenced by circulation and measurement conditions. We hypothesized that focal low BBB permeability values can predict the spatial distribution of hemorrhagic transformation and global high BBB permeability values can predict the likelihood of hemorrhagic transformation. MATERIALS AND METHODS We retrospectively enrolled 106 patients with hemispheric stroke who received intra-arterial thrombolytic treatment. Ktrans maps were obtained with first-pass perfusion CT data. The Ktrans values at the region level, obtained with the Alberta Stroke Program Early CT Score system, were compared to determine the differences between the hemorrhagic transformation and nonhemorrhagic transformation regions. The Ktrans values of the whole ischemic region based on baseline perfusion CT were obtained as a variable to hemorrhagic transformation possibility at the global level. RESULTS Forty-eight (45.3%) patients had hemorrhagic transformation, and 21 (19.8%) had symptomatic intracranial hemorrhage. At the region level, there were 82 ROIs with hemorrhagic transformation and parenchymal hemorrhage with a mean Ktrans, 0.5 ± 0.5/min, which was significantly lower than that in the nonhemorrhagic transformation regions (P < .01). The mean Ktrans value of 615 nonhemorrhagic transformation ROIs was 0.7 ± 0.6/min. At the global level, there was a significant difference (P = .01) between the mean Ktrans values of patients with symptomatic intracranial hemorrhage (1.3 ± 0.9) and those without symptomatic intracranial hemorrhage (0.8 ± 0.4). Only a high Ktrans value at the global level could predict the occurrence of symptomatic intracranial hemorrhage (P < .01; OR = 5.04; 95% CI, 2.01-12.65). CONCLUSIONS Global high Ktrans values can predict the likelihood of hemorrhagic transformation or symptomatic intracranial hemorrhage at the patient level, whereas focal low Ktrans values can predict the spatial distributions of hemorrhagic transformation at the region level.
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Affiliation(s)
- Y Li
- From the Department of Neurology (Y.L., H.C., N.L., W.Z.), PLA Army General Hospital, Beijing, China
- Department of Radiology (Y.L., M.W.), Neuroradiology Section, Stanford University, Stanford, California
| | - Y Xia
- Department of Critical Care Medicine (Y.X.), Yantai Yuhuangding Hospital, Shandong, China
| | - H Chen
- From the Department of Neurology (Y.L., H.C., N.L., W.Z.), PLA Army General Hospital, Beijing, China
| | - N Liu
- From the Department of Neurology (Y.L., H.C., N.L., W.Z.), PLA Army General Hospital, Beijing, China
| | - A Jackson
- Wolfson Molecular Imaging Centre (A.J.), University of Manchester, Manchester, UK
| | - M Wintermark
- Department of Radiology (Y.L., M.W.), Neuroradiology Section, Stanford University, Stanford, California
| | - Y Zhang
- Department of Neurology (Y.Z.), Changhai Hospital, Second Military Medical University, Shanghai, China
| | - J Hu
- Department of Neurology (J.H., G.Z.), Southwest Hospital, Third Military Medical University, Chongqing, China
| | - B Wu
- Department of Radiology (B.W.), PLA Army General Hospital, Beijing, China
| | - W Zhang
- From the Department of Neurology (Y.L., H.C., N.L., W.Z.), PLA Army General Hospital, Beijing, China
| | - J Tu
- Outpatient Department (J.T.), PLA 61889 Army, Beijing, China
| | - Z Su
- GE Healthcare (Z.S.), Beijing, China.
| | - G Zhu
- Department of Neurology (J.H., G.Z.), Southwest Hospital, Third Military Medical University, Chongqing, China
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Li Q, Gao X, Yao Z, Feng X, He H, Xue J, Gao P, Yang L, Cheng X, Chen W, Yang Y. Permeability Surface of Deep Middle Cerebral Artery Territory on Computed Tomographic Perfusion Predicts Hemorrhagic Transformation After Stroke. Stroke 2017; 48:2412-2418. [PMID: 28775139 DOI: 10.1161/strokeaha.117.017486] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/22/2017] [Accepted: 07/10/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Permeability surface (PS) on computed tomographic perfusion reflects blood-brain barrier permeability and is related to hemorrhagic transformation (HT). HT of deep middle cerebral artery (MCA) territory can occur after recanalization of proximal large-vessel occlusion. We aimed to determine the relationship between HT and PS of deep MCA territory. METHODS We retrospectively reviewed 70 consecutive acute ischemic stroke patients presenting with occlusion of the distal internal carotid artery or M1 segment of the MCA. All patients underwent computed tomographic perfusion within 6 hours after symptom onset. Computed tomographic perfusion data were postprocessed to generate maps of different perfusion parameters. Risk factors were identified for increased deep MCA territory PS. Receiver operating characteristic curve analysis was performed to calculate the optimal PS threshold to predict HT of deep MCA territory. RESULTS Increased PS was associated with HT of deep MCA territory. After adjustments for age, sex, onset time to computed tomographic perfusion, and baseline National Institutes of Health Stroke Scale, poor collateral status (odds ratio, 7.8; 95% confidence interval, 1.67-37.14; P=0.009) and proximal MCA-M1 occlusion (odds ratio, 4.12; 95% confidence interval, 1.03-16.52; P=0.045) were independently associated with increased deep MCA territory PS. Relative PS most accurately predicted HT of deep MCA territory (area under curve, 0.94; optimal threshold, 2.89). CONCLUSIONS Increased PS can predict HT of deep MCA territory after recanalization therapy for cerebral proximal large-vessel occlusion. Proximal MCA-M1 complete occlusion and distal internal carotid artery occlusion in conjunction with poor collaterals elevate deep MCA territory PS.
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Affiliation(s)
- Qiao Li
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Xinyi Gao
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Zhenwei Yao
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Xiaoyuan Feng
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Huijin He
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.).
| | - Jing Xue
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Peiyi Gao
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Lumeng Yang
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Xin Cheng
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Weijian Chen
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
| | - Yunjun Yang
- From the Departments of Radiology (Q.L., X.G., Z.Y., X.F., H.H.) and Neurology (L.Y., X.C.), Huashan Hospital, Fudan University, Shanghai, China; Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (J.X., P.G.); Department of Radiology, The First Affiliated Hospital, Wenzhou Medical University, China (W.C., Y.Y.)
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